History of the present illness explained

History of the present illness should not be confused with Past medical history.

Following the chief complaint in medical history taking, a history of the present illness (abbreviated HPI)[1] (termed history of presenting complaint (HPC) in the UK) refers to a detailed interview prompted by the chief complaint or presenting symptom (for example, pain).

Questions to include

Different sources include different questions to be asked while conducting an HPI.

Several acronyms have been developed to categorize the appropriate questions to include.

The Centers for Medicare and Medicaid Services has published criteria for what constitutes a reimbursable HPI. A "brief HPI" constitutes one to three of these elements. An "extended HPI" includes four or more of these elements.[2] [3]

CMS"OLDCARTS""OPQRST"[4] [5]
or "PQRST"[6] [7]
"LOCATES""CLEARAST"[8] "LIQOR AAA"[9] "SCHOLAR"[10]
("S" = Symptoms)
"COLDER AS"
location"L": Location"R": Region and Radiation"L" : Location"L": Location"L": Location"L:" Location"L:" Location
quality"C": Character"Q": Quality of the pain"C": Character"C": Character"Q": Quality"C:" Characteristics"C": Character
"R": Radiation"R": Radiationsee above"R": Radiation
severity"S": Severity-how disruptive"S": Severity"S": Severity"S": Severity"I": Intensitysee above"S": Severity
duration"O": Onset"D": Duration"O": Onset"T": Time"T": Time frame"O": Onset"O:" Onset
"H:" History
"D:" Duration
timing"T:" Timing"T": Timesee abovesee abovesee abovesee above"O": Onset
context"E": Environment
modifying factors"A": Aggravating factors"R": Relieving factors"P": Provocation or Palliation"A" Alleviating/Aggravating Factors"E": Exacerbation"A": Aggravating factors"A:" Aggravating factors"E:" Exacerbation
"A": Alleviation"A": Alleviating factors"R:" Remitting factors"R:" Remitting factors
associated signs & symptoms"O": Other symptoms"A": associated symptoms"A": Associated symptomssee above"A": Associated symptoms

Also usable is SOCRATES. For chronic pain, the Stanford Five may be assessed to understand the pain experience from the patient's primary belief system.

See also

External links

Notes and References

  1. Adler HM . The history of the present illness as treatment: who's listening, and why does it matter? . J Am Board Fam Pract . 10 . 1 . 28–35 . 1997 . 9018660 .
  2. http://www.emrconsultant.com/emr_EMcoding.php Evaluation and Management Coding and Electronic Health Records
  3. Web site: Compliance Training Manual. www.usc.edu . https://web.archive.org/web/20010503032321/http://www.usc.edu/health/uscp/compliance/tm6.html . 2001-05-03.
  4. Web site: Medical Assessment . 2006-09-26 . https://web.archive.org/web/20070225123304/http://www.hopperinstitute.com/emt_medical.html . 2007-02-25 . dead .
  5. http://www.alpharubicon.com/med/medaccesshaumanao.htm Learning To Perform a Medical Assessment – Part 1: Quick Medical Assessment
  6. Web site: WEMSI – Assessment by PQRST . 2006-09-26 . https://web.archive.org/web/19981206081128/http://www.wemsi.org/pqrst.html . 1998-12-06 . dead .
  7. https://www.usask.ca/medicine/medicine/clsc.htm Department of Medicine Home Page
  8. http://dartmed.dartmouth.edu/spring06/html/student_notebook.php Dartmouth Medicine Magazine :: Student Notebook
  9. Web site: HPI (history of present illness) . 2006-09-26 . https://web.archive.org/web/20061004165948/http://www.aippg.net/forum/viewtopic.php?p=71106 . 2006-10-04 . dead .
  10. Buring SM, Kirby J, Conrad WF . A structured approach for teaching students to counsel self-care patients . Am J Pharm Educ . 71 . 1 . 8 . February 2007 . 17429508 . 1847542 . 10.5688/aj710108.